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Remifentanil Supplementation during a Cesarean Delivery under Regional Anesthesia: A Case Report
Abstract Number: T-55
Abstract Type: Case Report/Case Series
Introduction: Regional anesthesia (RA) is the preferred technique for patients undergoing Cesarean deliveries. Despite the reliability of neuraxial techniques, between 7-42% of parturients demonstrate perioperative pain (1). We report a patient, who displayed moderate pain during a Cesarean, who was spared a conversion to general anesthesia (GA) by an infusion of remifentanil.
Case: A 33 year-old G4P3 (60kg) presented in premature labor at 27 weeks. Cesarean delivery was planned due to breech presentation. Spinal anesthesia was accomplished with 27G Whitacre needle at L3/4 with 12 mg 0.75% hyperbaric bupivacaine,15 μg fentanyl and 0.15mg epimorphine. Advanced motor block and sensory block to ice at T3 noted 5 minutes post injection. At 47 minutes post injection, the patient started feeling moderate pain with peritoneal closure. Despite fentanyl 50 μg and midazolam 2 mg, her pain persisted. We discussed conversion to GA but she requested more attempts at analgesia. Thus, an infusion of IV remifentanil was initiated, with a bolus of 40 μg followed by an infusion of 0.2 μg/kg/min, which completely resolved her symptoms. The infusion was progressively decreased, kept between 0.07 and 0.1 μg/kg/min by following pain assessments. The infusion continued for 20 minutes, in which a total of 143 μg of remifentanil was given. O2 via facemask with ETCO2 monitoring maintained throughout. No episodes of apnea or O2 desaturation were noted. The patient arrived in the recovery room stable, with moderate pain, but completely satisfied with our chosen technique.
Discussion: Remifentanil is an ultra-short acting opioid, unique for its pharmacokinetic profile. Its short blood-brain equilibration and context sensitive half times of 1.3 and 3 minutes respectively make it an attractive drug in obstetric anesthesia. This report is the first case of a patient in which supplemental remifentanil was administered for persistent pain during a C-Section under RA.
The use of remifentanil as a supplement to RA has been shown safe and effective in non-obstetrical settings. Side effects include respiratory depression, pruritus, nausea/vomiting and hemodynamic instability. A 1999 meta-analysis suggested 0.1 μg/kg/min as an optimal dose, balancing side-effects and sedative effect. We recommend using pre-gestational lean body weight, starting with an initial bolus of 0.5 μg/kg, followed by an infusion of 0.1 μg/kg/min. This low dose considers the pregnancy-induced sensitivity to depressant medications. We recommend early O2 use, along with continuous SPO2 and ETCO2 monitoring for accurate assessment of respiratory rate. Moreover, we recommend continuously talking to the patient. This report shows this technique may be safe, efficient, with high maternal satisfaction. Moreover, we successfully avoided conversion to GA with our use of remifentanil. Further prospective studies are needed to confirm generalized safety and efficacy of this technique.
1.Davies,Anesth Analg 1997;85:607